Basic Information
Provider Information | |||||||||
NPI: | 1124076278 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REYNOLDS | ||||||||
FirstName: | KATHY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1450 NW 0090 | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554850090 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002791395 | ||||||||
FaxNumber: | 5176946441 | ||||||||
Practice Location | |||||||||
Address1: | 800 EAST 21ST STREET | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571051016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053228000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 11/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 4743 | SD | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 208000000X | 9701856 | NC | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0203X | 11712 | NV | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0214X | 4743 | SD | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080P0204X | 38372 | CO | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
ID | Type | State | Issuer | Description | 891113P | 05 | NC |   | MEDICAID | 002019725 | 05 | NV |   | MEDICAID | 64900789 | 05 | CO |   | MEDICAID | 063407700 | 05 | MN |   | MEDICAID | 6700510 | 05 | SD |   | MEDICAID |